Psychosocial rehabilitation aims at helping
people with chronic mental illness to reduce disabilities and improve
capabilities to the maximum extent possible so as to integrate them into the
family and the community. Therapeutic community (TC) approach is one of
the approaches to rehabilitation. This approach refers to milieu therapy
that focuses on creating a supportive environment which by itself is
therapeutic. Psychosocial rehabilitation programs following a TC approach
are comprehensive programs which offer various therapeutic services and
activities. One such intervention is group therapy. The present
paper attempts to focus on the role of group therapy in a half way home
following the TC approach. Following archival research paradigm, all the
documented group therapy sessions from 2008 to 2014 were analysed for their
themes and techniques. The results have been discussed in view of the
themes and content and techniques and the process. The analysis suggests
Theme Centred Interactional approach has been followed. Themes that were
frequently focused on are: living skills, social skills and personal issues
followed by psycho-education about mental and medical illnesses and family
relationships. Techniques include role plays, ‘go round’, group
discussions, small group activities, group games and sharing and narrating
experiences. All of them promoted group interaction and
communication. Overall improvement was reported as assessed on a
standardized progress checklist.

Treatment
of chronic mental illness, especially schizophrenia, has remained a challenge
for mental health professionals. The treatment process has been described
as occurring in two phases: 1) a stabilization phase, wherein the focus is on
reducing symptoms, especially the positive symptoms and maintaining the
patients free of symptoms to the extent possible; 2) a rehabilitation phase,
wherein the emphasis is on reducing disability, improving skills of daily
living, personal care, social skills and social adjustment, interpersonal
relationship, and vocational skills (Breier and Strauss, 1984). Improvement in
these areas takes place much more slowly and these are open to influences of
multiple factors in the environment. As a consequence they are difficult
to assess (Stone, 1998). Rehabilitation can occur in the hospital
settings, at home or in rehabilitation centres, either residential or day
care. Importance of psychosocial intervention in the treatment of
schizophrenia is well recognized and established.

Psychosocial rehabilitation interventions aim at helping people with chronic
mental illness to learn or relearn skills, improve their abilities, and reduce
their disabilities. Ultimate goal of such intervention is to achieve the
maximum level of functioning as is possible. In the rehabilitation phase
long-term interventions including individual and group interventions can play a
significant role. Rehabilitation in a residential care facility is also
influenced by the approach followed in the set up.

One of the approaches that has been tried to achieve rehabilitation is the
Therapeutic Community (TC) approach. Therapeutic communities are small cohesive
communities based on ideas of collective responsibility, citizenship and
empowerment. They are structured to encourage personal responsibility and avoid
unhelpful dependency on professionals. (Campling, 2001). In a TC, the
day-to-day experience of living and working together is as important as formal
therapy, and the community is structured in such a way as to maximize
opportunities for “the living–learning experience” (Campling,
2001). TC is an extension of milieu therapy which focuses on change
and recovery in the context of living in a community. The environment
following the principles of ‘democratization’, ‘permissiveness’, ‘communalism’,
and ‘reality confrontation’ is in itself therapeutic. The community by
itself has a therapeutic influence on every member. Elly Jansen, credited for
introducing therapeutic community approach to patient care at Richmond
Fellowship Society, in the United Kingdom (UK), concurs that the essence of a
therapeutic community is the deliberate creation of a group that influences the
social group interactions. The Community consists of a consciously contrived
group of people who share all aspects of their daily life i.e. chores and
leisure activities, problems and triumphs, distress and happiness. In the
process, relationships are formed in a spontaneous way. These become
therapeutic i.e., healing, supportive and life-enhancing (Jansen, 1985)

Use of group intervention in the treatment of schizophrenia has a long
history. Lazell (1921) was first to report the advantage of group therapy
for schizophrenia patients. Payn (1965, 1974) reported the advantages of
group therapy in providing socializing experiences for patients that diminish
anxiety, improve reality testing, increase self-esteem, and reduce necessity
for hospitalization. O’Brien et al (1972) reported that group treatment
improves medication compliance. Improvement in social functioning has
been reported by many authors (Masnik et al., 1971, Donlon et al, 1973).
There are reports of comparisons of the efficacy of group and individual
treatments, and out-patient and inpatient group treatments. Compared to
individual treatment group treatment have been found to be effective in
reducing re-hospitalization (Prince et al; 1973), and in improving interpersonal
relationships (Claghorn et al, 1974). ). In a therapeutic community
certain things are a basic necessity for the community to survive through the
cooperation of its members. Having a structure to the day to day functioning,
having a specific routine, a time to meet at a table, a time to meet during the
week to address various issues of the community and even personal concerns, are
few of them. (Jansen E, 1980)

Approaches to group treatment vary from therapist to therapist in terms of
their theoretical orientation and the set up in which therapy is conducted.
Kanas(1999) mentions three fundamental approaches: Educative, Psychodynamic,
and Interpersonal. He is of the opinion that group therapy is the primary
socializing experience for persons with chronic mental illness. According
to him insight-oriented techniques should be avoided as many of them may be
harmed by too much uncovering and self-disclosure. He suggests the group
therapist or facilitator to be active and directive in keeping group members
focused on the topic; clear, consistent and concrete with interventions;
supportive and diplomatic with comments; open and willing to give opinions
appropriate to discussion; here-and-now focused; encouraging of
patient-to-patient interactions. Kanas (1998) also contends that groups
are useful in improving psychosocial functioning, increasing school and work
productivity, and reducing the number of days of future hospitalization among
bipolar patients.

In recent years a long-term group therapy called Multimodal Integrative
Cognitive Stimulating Group Therapy (MICST) has been suggested. This
modal is based on the theory that views schizophrenia as a condition
characterized by deficits in information processing and memory deficits which interfere
with communication and interpersonal relations. The therapy combines
elements of social skills, relaxation exercise, cognitive retraining, and
traditional psychotherapy (Ahmed 2003). Roder et al (2011) in their
meta-analytic update report positive outcome of Integrated Psychological
Therapy (IPT). They put forth empirical evidence indicating that IPT is
an effective rehabilitation approach for patients with schizophrenia. IPT
is a group therapy program that combines neurocognitive and social cognitive
interventions with social skills and problem solving approaches.

Psycho-educational Multiple-Family Group treatment among patients with
schizophrenia has shown reduced rate of psychiatric hospitalization (Dyck,
2002). According to Stone (1998) “Research findings of psychotherapy of
schizophrenia have not been robust, and as a result, research efforts in this
area have nearly vanished. This has occurred in part because of the
hypothesized lack of effectiveness of psychotherapy when compared with medications.
The difficulties are magnified when it comes to research on group treatment.”

Though there are reports of group therapy in inpatient settings and outpatient
settings (Kanas 1985, 1986), short term and long term group intervention
(Kanas, 1991; Kibel 1981, 1984), less is reported on group interventions in
rehabilitation phase especially as a component of psychosocial rehabilitation
program in a residential set up. One would hardly find any report on the
effectiveness of group interventions by Indian researchers. Hence, the
present attempt at understanding group intervention in a residential
rehabilitation setting.

Aim:
The
present paper attempts to understand the role of group intervention in a
Therapeutic Community (TC) for persons with chronic mental illness.

Methodology: This is
an Archival Research. Documents pertaining to Group Interventions in a
Half-way-home, ASHA, run by the Richmond Fellowship Society, in Bangalore,
India, for chronically mentally ill persons formed the source of data.

The “Asha” halfway home is a residential facility for both men and women,
and can accommodate 21 adults with SMI (mostly schizophrenia and affective
disorders. Members (referred to as residents) play a significant role in
decision-making and running the programs. Residents, depending on their
ability, interest and stage of recovery, actively involve themselves in
responsibilities and duties around the house and contribute in various
capacities in managing the day-to-day affairs of the facility. In
addition to following the principles of therapeutic community (TC), the center
offers other therapeutic activities i.e. group interventions, individual
counseling, art and movement activities, vocational training, cognitive
retraining and family intervention. The center incorporates various
features of a TC. It is run on the understanding that there is 1) Free
communication, 2) Sharing of responsibilities, 3) Decision making by consensus,
4) Analysis of events, 5) Provision for living – learning opportunities, 6)
Examining roles and role relationships, and 7) Flattening of the authority
pyramid (Kalyanasundaram and Murthy, 2000).

A thematic analysis of the documented group intervention from the year 2008 to
2014 was carried out (7 years). The records were analyzed in terms of:

•
Number of sessions and duration of sessions
• Number of participants
• Themes of group intervention
• Techniques employed
• Perceived benefit and documented progress

Results: A total
of 267 sessions were recorded indicating approximately 38 sessions per year
(about 3 sessions a month). Number of participants varied from 10 to 16,
both men and women. The diagnostic categories were Schizophrenia, Bipolar
Affective Disorder, and Major Depression. Length of each session varied
from 75 to 90 minutes. The records were analyzed for the themes they
addressed. The themes could be categorized into the following 6 major
categories with some overlap:

Being a part of a residential rehabilitation center the groups were open groups
wherein new members replaced those who were leaving after having completed
their stay and launching out. The Group had set rules and norms which
were followed. Reminding the members of these norms from time to time was
found to be necessary. The preparation for the intervention session followed a
specific procedure of A) Pre-session discussion among the staff team, wherein
the main facilitator and co-facilitator were identified, the theme was decided
based on the felt need and participants’ views. In addition suitable techniques
to be used were discussed and decided upon; B) Group therapy session as per the
pre-session discussion; C) Post-session briefing among the staff team.

Group
session:The session can be explained in the following steps: 1) Members greeting each
other and the facilitators; 2) a brief period of silence when the members were
encouraged to orient themselves to the present and also reflect upon the
previous session. If any member wished to bring in specific issues, they were
addressed; 3) introduction of the theme/topic to the group by the facilitators
and eliciting members’ views; 4) use of different techniques depending on the
theme so as to initiate the process; 5) feedback from each member about the
session, their experience and learning from the session; 6) summarization of
the session by the facilitators. Emphasis was placed on practicing the
skills and implementing the learning in real situations.

The therapeutic techniques that were used were as follows:

•
Group discussion
• Small group activity and sharing
• Role plays
• Modeling and demonstration
• Group games with specific purpose
• Narration of experience
• ‘Go around’: This is a method to get people to
communicate. The therapist asks each member to give his/her opinion on a
particular subject. The subject may be something that has occurred in the
session, in the community, or something that is related to the personal life.

Impact of the sessions was assessed on a progress checklist, staff observation
of the day-to-day behavior and as reported by the participants. As a routine
practice the residents were assessed on IDEAS at the entry point. Once in
a month each of the residents was assessed on a standardized progress checklist
(Chowdur, 2011). The check list includes 10 specific areas i.e.
Self-care, Following routine, Interpersonal relations, Participation in leisure
activities, Communication, Vocational activities, Family relationship, General
behavior, Money management, and Moving around. Specific positive impact
was seen in the following areas:

•
Improved health related behavior, especially medication compliance
• Improved general behavior (interpersonal relationship) within
the community
• Better social skills (interpersonal interaction and
communication)
• Improved personal skills (engaging in leisure activities,
living skills, vocational activities)
• Improved relationship with family members as reported by
the family members
• Participants also shared personal issues related to the
themes which they had not shared earlier. These were then addressed in
the individual sessions.

Overall impact of psychosocial rehabilitation program at the half-way-home on
the recovery of the residents has been reported elsewhere (Chowdur et al, 2011)
Discussion: Psychosocial rehabilitation programs are designed to facilitate
over-all recovery of the clients. In a residential setting, which
integrates different modes of therapies, one cannot separate the impact of
specific therapy on the recovery. At the ‘ASHA’ half-way-home, in
addition to following a TC approach, other therapeutic inputs come from
individual therapy sessions, art work, dance and movement activity, vocational
training and Group therapy. Considering the comprehensive program it may
not be appropriate to attribute the change and progress in recovery to any one
therapeutic mode, to group therapy in the present context. However,
therapist report and clients specific and personal feedback bring to focus the
importance and benefit of group intervention for the residents.

Theme
and Content:Selection
of themes was based on staff team’s observed and perceived needs of the
residents in addition to the residents’ expressed need. Maximum number of
sessions focused on Social Skills (75), Personal issues (73) and Life Skills
(71). Social skills included communications skills, behavior in public
places, cooperation, assertiveness skills, conflict management etc. Personal
issues included personal goal setting, self-esteem, self-confidence, sharing
personal stories, experiences and concerns, self-awareness, understanding
one’s own needs, empathy, problems and concerns, attitudes etc. Life skills
were to do with skills like managing time, problem solving skills, stress and
coping with stress, self-care, managing/regulating emotions, taking
responsibility, leisure time engagement, personal hygiene, health care,
motivation etc. Another significant theme that was covered was
psycho-education about both medical and mental illnesses. Important medical
health concerns were those of general health, obesity and diabetes.
Mental health concerns related to illnesses like anxiety, depression,
schizophrenia and bipolar affective disorder. The theme ‘family’
overlapped with two other themes i.e. social skills (interpersonal
relations/interaction) and personal issues (attitudes) as they involved common
issues of interpersonal skills and attitude. Moreover, family issues are
addressed in family sessions which form an integral part of the Psychosocial
Rehabilitation (PSR) program. Few themes related to social responsibility were
also taken up like following traffic rules, law and legislation, use and abuse
of tobacco, social obligations, etc. Coursey et al (1993) in a study
found that when chronically ill patients in a rehabilitation setting rated
therapy topics, out of 40 therapeutic topics, the highest rated items
clustered in a category described as “illness-intensified life issues” which
encompassed independence, developing self-esteem, relationships, and
feelings. Other categories that were rated as important include adverse
secondary consequences of illness, self-management of the disorder and coming
to terms with the disability. In the present study it was noted that
residents were not inclined to discuss personal/private issues of self-esteem,
perceived stigma, and some relationship issues in the group. However, they had
the opportunity and preferred to address these issues in individual therapy
sessions. Long (1996) also suggests that positive results are more likely
when group therapy focuses on real life plans, problems, and relationships; on
social and work roles and interaction; on some practical recreational or work
activity. Discussion on cooperation with drug therapy and its side
effects is also advantageous. Supportive group therapy can be especially
helpful in decreasing social isolation and increasing reality testing. Techniques
and Process:Group
therapy focused on both content and the process depending on the theme.
Most often they occurred simultaneously. The themes or content lent themselves
to promote a living-learning experience, sharing and social interaction in a
non-threatening and nonjudgmental environment, and helped to engage in reality
based conversation. The techniques used in the sessions facilitated
the same. Group discussion helped an adult to adult verbal interaction in
a socially appropriate and acceptable way on the part of the therapist /
facilitator and listening and respecting others view on the part of other
participants. Members made an attempt to understand the issues from different
perspectives and from other’s point of view. This provided an opportunity
to learn from the experiences of others and also learning from their coping
skills. This also facilitated better understanding among the members.
Person to person interaction is proved to be of great value for members of the
community. ‘Go around’ stimulated interaction among group members,
especially those who were less communicative, reluctant to interact or
withdrawn. This encouraged group members to comment or express their views on
each other’s comments or views. ‘Go around’ also lent a structure to the
sessions. This technique was found to facilitate sharing of feelings and
promoted ventilation for some of the members. Role playing technique used
for behavioral training, helped to learn and practice social skills. Role
reversal enabled them to view situations from other’s point of view. Group
activities, including small group activities helped in creating cohesion in the
group by promoting cooperation and coordination among its members as they had
to work together to achieve a common goal. This was also reflected in the day to
day behavior of the members. Modeling and demonstration involved therapist in
an educator’s role. O’Brien (1975) suggests similar methods to facilitate
groups. He suggests verbal and nonverbal interactions; go around; structured
dialogue; role playing; and group activities to be of advantage. The
routine activities including going out for purchases, going to a restaurant and
taking care of one self, etc. provide for practicing the learnt skills in the
real life situations.

Yalom (1970) suggests 12 factors in play in a group therapy especially in
psychodynamic approach. The 12 factors are Interpersonal learning,
Catharsis, Group cohesiveness, Self-understanding, Development of socialising
techniques, Existential factors, Universality, Instillation of hope, Altruism,
Corrective family re-enactment, Guidance, and Identification/imitative
behaviour. The present study suggests some similar factors coming into
play for the benefit of the members. These are interpersonal learning,
catharsis, group cohesiveness, developing socializing techniques, instillation
of hope, and guidance. However, not all the members experienced the same
benefits and to the same degree. Shaffer and Galinsky (1989) synthesized
the most frequently cited factors into five categories: Observation of self and
others; identifying and practicing new behaviours; recasting problems and
developing strengths; group support; and therapist’s observations. These
were also observed in the group therapy process.

The analysis indicates that the group intervention followed in the therapeutic
community is similar to the Theme Centered Interactional (Cohn, 1969) or the
Theme-Oriented Group Therapy (Opalic, 1988) approach. Though attending the
group sessions is mandatory for all in a therapeutic community, some of the
residents missed a session or two. Some degree of flexibility was
allowed in this area of attendance. Roback (1984) used the term Disease
Management Groups to refer to groups specifically created for patients having
the same illness. He describes the functions of a facilitator or leader
of such a group as “information disseminator”, “catalyst”, “orchestrator”, and
“model for learning”

Staff team role and responsibility: Group intervention sessions gave an
opportunity to the staff team to observe residents behavior, and interpersonal
interaction in a different setting which could not be seen in individual
sessions. Group intervention sessions also provided a platform to express
and discuss differences and conflicts between members by the residents as well
as the staff team. The group provided a safe environment to reflect on these
issues and resolve them.

The staff team who were also facilitators for the group required to be
supportive, and empathic. They were expected to be active and directive
in their approach. Patience on their part had a significant impact. And
being tactical, supportive and diplomatic with their comments was found
important. They had to be clear and consistent with interventions,
here-and-now focused, guiding and encouraging.

Challenges:
Getting
some of the residents to attend as well as participate in the session was a
difficult task. Schizophrenia, with its negative symptoms of low
motivation, disengagement, and apathy, particularly presented a therapeutic
challenge. Similarly, the fluctuating mood of persons with bipolar
affective disorder had a significant impact on their attending and
participating in the group session. Lack of insight or partial insight
into the illness which contributed to the resident’s difficulties in engaging
in therapeutic activities could have been another barrier, undeniably for the
new entrants of the community. The size of the group was larger than the
ideal and suggested size of 8-12 persons (O’Brien, 1975). Group of 10 to
16 members can present its own challenges like time, number of interactions,
more number of issues being brought in. It was felt that the normal time
of 45-60 minutes per session was inadequate for this group (10-16) as more
number of issues brought in by this larger number had to be dealt with. A
longer duration i.e. 75-90 minutes per session was found to be adequate. Being
open groups the changing group membership affected both, the cohesion and the
stability of the group. Preparing new members and helping them to become
integrated with the already existing group was an challenge.

Limitation:This
paper is based on archival research. Since, the source of data are the
previously recorded documents, the researchers had to go by what has been
recorded. Problem of inadequate documentation, missing data are its
limitations. Since group therapy was a component of the rehabilitation
plan the overall improvement and progress of the residents cannot be attributed
solely to group therapy.Conclusion:Despite
limitations the paper has been able to delineate the importance of group
intervention in a rehabilitation phase of chronic mental illness in a
residential set up. Opportunity for vicarious learning, skills learning and
practicing, group cohesiveness, group pressure, group support, understanding
and acceptance, positive regard, and safe space for ventilation were the most
significant aspects of the group that benefitted the members. It
brings to light the significance of including a well-planned group intervention
in the rehabilitation program for people with chronic mental illness. Group
therapy can contribute significantly in the recovery process. As O’Brien
(1975) opines “Group therapy blends well in an overall rehabilitation program
with pharmacotherapy, individual psychotherapy, family therapy, and a day
hospital program’. This is true of a community based residential
rehabilitation program too.

Acknowledgements:

The authors are grateful to Dr. Lata Hemchand
for her comments on the initial manuscript. We also acknowledge the
contribution of the professional staff at the half-way-home who have conducted
and facilitated the group intervention and documented it for the period under
discussion.